Ruminations by a non-academic general surgeon from the heart of the rust belt.

Sunday, February 10, 2013

Dash 22

The consult came in around 3:30 on a Friday. The surgeon wasn't on call but his partner was tied up and he, the surgeon, felt obligated to see the new patient before it got too late. To do otherwise is known as a "dick move" in the world of small private surgical practice. The computer record outlined the picture of a man in his late seventies with an unremarkable medical history. He only took something for gout and various other over the counter vitamins. He took something called Life-X 3000. The consult request was "evaluate for gallbladder disease". The patient had been admitted three days prior. That was interesting. The admitting diagnosis was "diarrhea". The surgeon perused the completed blood work and imaging. Mildly elevated liver function tests. White blood count (WBC) over 20,000. The CT report had the surgeon logging out of the terminal and brisk walking to the other side of the hospital--- severe cholecystitis, possible malignancy vs liver abscess.
On the way to the patient's room the surgeon calls the OR desk to get an idea of how the board looks. This is the witching hour in the OR, when staff go home and the number of available OR suites whittles down to the bare minimum. This as a case that needed to go quick. He had seen this all before. Elderly male with leukocytosis and nasty gallbladder on US and/or CT. It was inevitably a mess. Gangrene. Pus everywhere. Long case. He thought of the tickets he had to that nights Cavs game and ran some mental computations, in terms of anticipated case start time and the likelihood of a long, grueling 90 minute cholecystectomy and the 25 minute drive downtown and fighting the serpentine, one way-heavy Cleveland traffic with too few cops and not enough parking and he figured he might as well just put the damn tickets on Flashseats right now.

As he approached the room he was surprised to hear baritone laughter and talking from multiple voices coming from behind the curtain. This was not the expected mood. What he expected was silence and a withered, ill-appearing old man grimacing under the sheets as his gallbladder rotted within his abdominal cavity. Maybe a frightened, cowering wife in a vinyl chair that made her look like a shrunken elderly pixie. The actual alleged patient was sitting up in bed laughing his ass off, apparently regaling various family members with some story of sufficient mirth /nostalgia/humor/etc. There were at least 8 people in the close quarters of the room. As the surgeon entered everyone turned and looked at him; the volume in the room fell, but the mood remained elevated. The faces turned to him still smiling. Someone said, Hey Doc. Typically the surgeon is a very shy man when it comes to public speaking. When he has to give a vanilla presentation on some generic topic like Your Appendix and You to a motley assortment of nurses, medical students, other physicians, technicians, transporters, etc., he stresses about it for weeks beforehand, spending sleepless nights editing lousy PowerPoint slides that no one will really pay attention to anyway. He was the sort of guy who had to dial a girls phone number 27 times in middle school before staying on the line long enough for the desired girl to answer. The idea of giving extemporaneous speeches in public, in general, causes him immense psychic pain. If he walks into the doctor's lounge and it's crowded with physicians he only peripherally knows, his face will glaze over with a sheen of sweat. But it's different when performing as a doctor/surgeon. You stride into a room and you really don't have any prepared remarks. Everyone has turned his/her gaze on you. Nervousness doesn't have time to infect the mind. You have too many other patients on the list to see. You have done this a million times before. Rote mechanical phrases are already forming on your lips. An easy affability starts projecting from your countenance like a meteor shower. Mr Hawkins, I can assume, he says. I'm Dr Parks, a surgeon. Dr. Heller asked me to get over to see you ASAP. The warm frat boy vigorous shaking of hands. The patient is at least 6'4" and well proportioned. He appears about 15 years younger than stated age. His hair is parted linearly, a scalp colored pale stripe running from front to back, and glistens somewhat in the well-lit room, unclear at this point whether water or hair gel. Good to meet you Doc. Old Heller told me all about ya. Said you'd fix me up. Now what are we going to do about this gallbladder business and when?

The surgeon smiles and says we'll get to that and then he meets all the family members firmly in the eye with his gaze, introducing himself, listening without remembering but also without being disrespectful or dismissive, as they voice their names and relationships to the old hale man, an unwavering expression of confidence and calm and projecting the notion that I am exactly the man to be interrupting your little family gathering reverie and you all had better listen up because we have some work to do.

The surgeon listens to heart and lungs and notes a sinus tachycardia. The abdomen is somewhat distended. A curved scar below the navel, like a complacent grin, is the only marking he sees. Hernia fixed here? he asks. Hell, that was years ago. Any idea if they stuck a mesh patch in there? Doc, I wouldn't know if they welded a chunk of sheet metal in there. Been so long. The surgeon smiles again and applies pressure to the old man's tanned upper abdomen. A slight but perceptible wince on his face and involuntary tightening on the abdominal musculature confirms the urgency. We need to get you downstairs to the OR. I suspect an unusually severe case of gallbladder disease. It's making you toxic. I want to get started with the surgery right away. The patient nods assent. Let's have you get this thing outta me then, he says.

His assistant for the case is an older tech named Philly. His real name is Phil but everyone calls him Philly. He isn't from Philadelphia. He grew up in southern Ohio and has been a surgical assistant for over thirty years. He worked in Cleveland originally but then moved to Florida with his wife for some reason or other. Now he is back in northeast Ohio part-time. His wife is still in Florida. Apparently her job pays well. Philly had lost his when a hospital outside Sarasota streamlined its OR services and cut 30 people from the payroll. He works weekends and nights now. By any metric, Philly is not considered one of the top assistants, or even a mediocre one. He does not have a natural, intuitive feel for how operations ought to proceed. He needs to be told what to do, each step of the way. The surgeon is not as bothered by this as some. He always feels he can compensate for less than ideal assistance. As a result, Philly is often assigned to his cases.

The patient is put to sleep by anesthesia. They need to add a table extension to the foot of the bed due to his size. His arms are abducted away from his torso at right angles, Christ-like. He lies nearly still, the endotracheal tube jutting toward the ceiling, his chest imperceptibly rising and falling with the applied tidal volumes. Philly begins to shave and prep the abdominal wall.

All right, here we go now. The surgeons struts into the OR freshly scrubbed hands and arms. His eyes pore over the sterile table, making sure all the proper ports have been selected, local anesthetic available, right sized clips, endo bag opened, camera angle 30 degrees, #15 blade (not the #11), Bovie machine set to 35/35 cut and cautery. He limns the field with the sterile blue towels and then the body is cloaked by the full length laparoscopic drape. The next three minutes are a flurry of organizational activities; unwinding all the cords and tubing in an unobtrusive manner and plugging things in and getting the laparoscopic monitor adjusted and and positioning the food petal and bringing the Mayo stand over the patient's legs. He accepts the hypodermic needle and injects the subcutaneous tissues of the infra-umbilical area with 0.5% Marcaine. The needle is exchanged for scalpel and he firmly presses the tip into flesh and slides it smoothly on a curvilinear path through he epidermis and dermis toward himself. S-retractors split the fatty tissue deep to skin and then the Bovie is used to sharply slice open the fascia. This all occurs within 60 seconds. A finger sweep to confirm a clean entry and then the port is inserted, the gas is hooked up and turned on, and now they are in business. The abdomen distends grotesquely, like starving Kwashiorkor-ravaged children in northern Africa. The thin sleek skewer-like 5mm/30 degree camera slides effortlessly through the port into the abdominal cavity.

Gimme gimme gimme....that 11 port first, he says. He makes a skin nick and then spears the 11 into place just below the xiphoid process. Two more 5mm ports are placed on oblique angles in the right upper quadrant. The gallbladder is nowhere to be seen. The omentum has rolled up against the under surface of the right lobe of the liver, obscuring everything, like some sort of yellowed snow drift cloaking the entrance of a driveway.
-Where the hell is it, the scrub nurse queries
-It's in there.
The surgeon asks for the suction dissector and uses the metallic tip to gently probe at the liver/omental interface. It isn't all that unusual in acute cholecystitis for the omentum to migrate to the inflamed gallbladder, as the body attempts to wall off a problem area. Typically, the adhesions from the omentum to the gallbladder and liver are easily disrupted with gentle probing of the natural tissue plane. This particular patient had been suffering for days. He prods at the omentum and it doesn't budge. Densely adherent. He spends the next ten minutes using cautery and sharp scissor dissection just to get the damn bag exposed.
-Alrighty. There it is. He pokes at a grayish orb peeking up from below the wave of omentum. The surface is the color of overnight dishwater. Splotches of greenish-black death are stellated across the dome of the ostensible gallbladder.
-Goddam, Philly says. You wanna get the open stuff ready?
The surgeon pauses, looks him over.
-Who's room you think this is? McQuaid's?

Now that the fundus of the bag is exposed, he can use the suction tip to develop the plane between the indurated inflamed fatty drapery and the gallbladder itself. It's like trying to peel a banana with a drum stick. He gets enough de-husked to allow for a grasper to grab the wall and heft it up over the liver. Philly thrusts his instrument into the rotten tissue and merely tears away a chunk of necrotic phlegm.

-Jesus Philly. Jesus man. The surgeon quick-thrusts the suction tip into the pus erupting hole and tries to aspirate out as much of the rot as he can.
-You can't do that dude. He looks at Philly a little too long.
-Alright Dr Parks. It's not like I meant to do it.

The surgeon repositions the grasper, finding an area of gallbladder wall less flimsy than the rest and is able to obtain decent purchase. He sticks in another port to retract the omentum out of the way. Slowly he raises the ashen sac up and over the liver edge. The solidity of the gallbladder is like if you took a fortune cookie and soaked it for an hour in a bowl of Won Ton soup and then tried to pick it up with chopsticks. The progress is slow and incremental. But progress it is. Always with the suction tip, alternating between pressing down and away toward the porta hepatitis and then inching down lower with the upward grasping force. The infundibulum finally starts to come into view, a curved baby bottom terminus of the damn thing. A large calcified stone is tactilely identified just above it.

-We're getting there, he says to no one in particular.
-Never a doubt, Philly says, smiling behind his mask.
-I still have no idea what we're looking at, the scrub nurse says.
-This is a dash 22 case guys, he says.
-A dash what?
-Dash 22. If I want to get paid for an operation I have to submit the appropriate code to the insurance company or Medicare. The Current Procedural Terminology (CPT) code for a standard lap chole is I think a 47563. That gets me about $750. But not all gallbags are the same. Doesn't seem right that I should get compensated the same for this disaster as I would for an outpatient 15 minute jobber, right? So they cut us a little slack. For really difficult ones, for the ones that make you want to strangle puppies when you're done, you can upcode the case by adding a -22 to the 47563.
-What you get extra for a dash 22?
-A monogrammed tote bag from CMS
-.(muffled)
-I have dozens of them.
-This one wasn't so bad, Philly says. If Medicare calls me to verify I'm going to tell 'em a monkey could've done it.
-Gimme that long bowel grasper.

The surgeon is able to get under the stone and grab the bulbous infundibulum and, by guiding it from one side to the next, is able to slowly dissect out the anterior and posterior components of Chalot's triangle. An artery starts to take shape. The tissues falls ways and he judiciously quick-suctions out the slow capillary ooze of the inflammatory sludge. What could only be a cystic duct materializes. He gently rolls the suction tip along its length. Up toward the liver plate he sees no intervening structures. Sometimes an aberrant duct or the common duct itself can loop up behind there. Everything looks clear. The artery is triple clipped and transected. He considers a cholangiogram but the duct looks like hell, grayish and starting to fray already under some minimal tension.

-Gimme the Endo Loop
-We need an Endo Loop, the scrub informs the circulating nurse. The surgeon sighs over loud. He could have indicated the possibility of needing one earlier but he was too engrossed. And the case has already gone over an hour. His nerves are already on edge. He closes his eyes and counts. 45 seconds feels like 4 hours when the circulator is out of the room looking for something you NEED RIGHT NOW. He can see the duct start to tear. Various epithets and depersonalized detritus spews from his mouth.
-Got it, the circulator says. All the way at the end of the hall.
It's opened and delivered to the field. He slices the papery tissue with endo shears and inserts the loop. The toothed grasper then passes through the loop and grabs the very cut end of the cystic duct. The loop cinches down tight. It's done. All that's left is the carving of the thing out of the liver bed.
-I'll take the hook. And crank the Bovie up to 45.

What follows is an exercise is pure torture. The gallbladder won't hold its structure. Philly has to manipulate it to the right and left as the surgeon basically burns the thing free and it's too much for him, Philly, the tissues aren't amenable and the surgeon starts to lose it, his cool. Come on man come on come on I need you to perform no no not good, not like that, gimme that grasper I got it I got it let me do it daddy do it let daddy take care of it, etc etc, the last frustrating soul crushing part and it's too much. The case time goes over the two hour mark. The back wall of the upper part of the fundus is completely liquified. It looks like congealed pan scum left over after cooking sausage and eggs for Sunday breakfast. Part of the necrosis extends into the actual liver parenchyma and tracts into a moderate sized abscess cavity. He sucks it all out. He's basically just scraping dead tissue from the liver. He gets it all out. He stuffs all the dead rot into the plastic retrieval bag. Nothing left to do but wash everything out and place a drain.

-Why you get like that, Philly says.
-Come on man. Come on. That was a frustrating case. I mean, come on. When a team is losing at halftime and the coach is tearing into everyone and losing his shit were you the guy you raised his hand and asked him why he had to be such a dick? Jesus man. It's not about your feelings. That case about sapped my living spirit.
-Hey Dr Parks. You're a talented surgeon. But you don't need to be so mean. Don't need to act like that. You're very skilled. I'm old enough to be you're father. I can't help you in the operating and the technical stuff but I can help you other ways. You don't have to be like that. You can be better...

The surgeon stares at the screen, irrigating and aspirating above and below the liver, rhythmically, over and over until the fluid starts to come back clear. There's no bleeding. The liver bed is dry.

-You're right Philly. I'm sorry man. Life is a process you know? I have things to get better at. You're right about that.
-You're all right Dr Parks. I like you man. Don't worry about it.
-You know there's probably only two or three surgeons in the tri-state area who could've done that case laparoscopically right? The surgeon is grinning behind the mask. He loves the faux bravado, which isn't actually all that faux when you break it down, more like deconstructed bravado, in a way that isn't so much arrogance or self assurance as it is a desperate cry for attention.

Out is the family waiting area, he approaches the hoard of Hawkins's with smiling confidence. He strides toward them. Well he's doing all right. Sorry it took so long. Worst one we've seen around here in a while. Yeah, dead, gangrene. A nasty gallbladder. Poor guy. I have no idea how he was walking around with it like that. Grateful smiles and handshakes all around and his wife hugs him. I'll make rounds early tomorrow. We'll see how he looks. I suspect a couple days of IV antibiotics. He heads to the locker room to change. The Cavs game is probably well into the second quarter by now. He texts his wife that he'll be home in half an hour.

On rounds the next morning the Surgeon first checks the old man's vitals and labs. Everything looks surprisingly good. No fevers or tachycardia. WBC already halved. And the liver tests are completely normal. He enters the room with some confidence but the bed is empty. Where the hell. He hears the water running in the bathroom. He's surprised to find the old man standing at the sink, lathering up his face for a shave. He looks like he's getting ready for work or a golf scramble. The surgeon just stands there in the entryway, staring.

-Hey Doc!
-Mr Hawkins. Damn. You're up and at 'em this morning. You doing ok?
-I feel great Doc. You did a great job. I felt the difference the minute I woke up last night.
-That's what I like to hear. He kneels briefly beside him to see the color of the drain output.
-I'm so glad you're here this morning. I've been wanting to thank you all night.
-Just doing the job.... It's what we're here for. He looks down at the floor, averting the old man's piercing unwavering eye contact, shuffles awkwardly away from him through the bathroom entry.
-No really. Listen to me. Listen. This is very important. I ran a successful business for 30 years and I hired and fired guys and I think I have a pretty good handle on human psychology. Listen to me. I know guys like you. Type A, driven. You got to learn to slow it down sometimes. Learn to listen when someone tries to compliment you. You don't have to go around all the time like you don't need anybody telling you that you done good. Everybody needs that. You don't have to wall yourself off all the damn time. You helped me and I really appreciate it. I have 6 acres of property I have to attend to this spring. I got no time for bein' sick. I feel like a million bucks already.

The surgeon inexplicably feels like a little boy again. Yes sir, he says. The white coat seems ridiculous, hanging from his shoulders like a costume. He wants to make sure the old man has enough towels.

-Let me ask you something. Your daddy around when you were a kid?
-Sort of. Not really. He lived in Arizona after the divorce.
-I figured as such. You look fit. You used to be an athlete, sports and the like in high school?
-I played soccer yes. I played. I was a decent athlete for a little guy.
-Your daddy wasn't around when you were getting those good grades and scoring goals was he?

The razor blade slides effortlessly across the angle of his jaw. His skin glistens smooth and almost metallic in the light. He isn't looking at the surgeon at the moment, focused entirely on accurate, non-nick inducing razor passes.

-Not a whole lot. I know he's proud of me though, the surgeon intones quietly. He finds himself backing up and sitting in the vinyl chair facing the entrance to the bathroom. The chair is too low to the ground and the back is positioned too far from the front edge of the seat so the effect is to recreate the iconic image of the Hitachi Maxell stereo ad (without the force of sound waves blowing back his hair); his back concave forward and awkward, legs spread wider than a normal stance.
-I'm sure he is. He better be. But you have to be careful. All those years acting like it didn't matter if anyone complimented you or not. If anyone was paying you any mind. Building up a wall of defiance. It can make a man resentful over time. It's OK to need affirmation. You don't always have to be the tough guy. You're still young enough. You don't have to end up small and hard and bitter. There's time for you.

He turns and looks at the surgeon as he wipes the disposable razor clean across a laundered white towel.

-Anyway, I wanted to thank you.
-Yes sir
-You have kids of your own?
-Yes I do. A girl and a boy. Three and 18 months. He starts to feel a deep ache in his chest and throat if he tries to breath too deeply or quick. His voice sounds far far away from where it is actually coming from.

-Well you best not dawdle here all morning. I'm sure you have plenty of people to see yet on your rounds.
-Yes, a mere whisper.
-Get your work done so you can drive home to those children.

He watches the old man squeeze cheap red gelatinous shampoo onto his palm from a mini-bottle, like in hotels, clasp the hands together to spread it evenly across both palms, and then start to smear the shampoo across his scalp, slowly constructing a foamed froth of soap and bubbles.

-And when they get older make sure you aren't wasting all your weekends in hospitals taking care of old bastards like me. Get another partner. Take a pay cut. Be with your children. Especially that boy.
He turns to look at the surgeon again, toothbrush in hand.
-Especially that boy. Whether he's catching or throwing or scoring or, hell, who knows, even if he's singing and dancing, it don't matter, you make sure that boy always knows your eyes are on him.
He turns back to the mirror to knead his frothed scalp.
-A boy needs that, he says.

The surgeon nods again, whispers something inaudible. If he breaths too deeply something structurally essential will fall apart inside his chest, he feels, like his ribs would suddenly detach from their spinal insertions and his thorax will collapse like a detonated old warehouse. Talking would be too much.
The old man starts to run the hot water in the sink. In anticipation of rinsing his hair. The steam rises languidly. The surgeon is frozen momentarily in the vinyl chair. He clutches his patient list, white knuckled. He cannot move or even breath properly yet. He has a sliver of time. He watches the tall, proud old man knead his scalp. Seconds stretched out into microcosmal swaths of eternity. The old man is rinsing his dyed black hair, bent forward, leaning forward into the mirror, his eyes closed, his hair a black forward-hanging sheen, like kelp washed up on the shore, and before he has a chance to open his eyes again, the surgeon is gone.

Dr P, Truely inspiring. A brief look into your life and the thought process you go through every day. I've been in his place and those 2 words, thank you, seem so small and insignificant, yet they do hold so much meaning. As a patient we tend to just want to feel better not realizing all that feeling better involves. What you and your team go through for the patient is inspiring. I am sure many patients have spoken those words to you yet again they seem so small but yet you have given a normalcy back to life again. The true meaning in those two words, thank you, are there, so please hear them and if the day has stepped in and you just move going through the motions, and need to understand your impact on the lives you have touched, read the words, they are there, in the lockbox.

Thank you for this story!I could not stop reading it. I reminded me so much of my mom's case and what a wonderful surgeon she had. Thanks for sharing your stories. I am not in the medical field, but in something very different, engineering and after reading a few of you stories it really helped understand so many things that happened at the hospital during my mom's stay. I hope you keep writing so I can continue to learn.

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